Insulin Pump/AID Management Note

Date of Service: [Date]

Visit Type: [in-person / telehealth]

Participants: [Patient name/initials]; [Caregiver/guardian if applicable]; [Diabetes educator if present]

Reason for Visit: [Device-focused chief concern]

Data Sources Reviewed: [pump download / CGM portal / pump+CGM integrated report / patient-reported log / device screenshots / prior note]

Download Window: [Start date] – [End date]; [Number of days captured]

Technology Summary

• Insulin Delivery System: [Manufacturer]; [Model]; [therapy mode: pump-only / AID / hybrid closed loop]; [auto/closed loop status: active / inactive]; [Insulin type in pump]
• CGM System: [Manufacturer]; [Model]; [integration status: integrated / standalone / not used]
• Infusion Set/Pod: [Type]; [Change frequency]; [Recent site issues if any]
• Back-up Plan: [Back-up insulin method: pen / syringe / basal insulin]; [Ketone testing access: urine / blood / none]

(If any device element cannot be verified, document what is missing, why, and how it was managed.)

Current Settings

(Document only verified settings as downloaded or directly observed on-device. Do not infer from glucose patterns. Remove or add rows as needed for the patient's system.)

Parameter	Time Block	Value
Basal Rate	[Time block or "all day"]	[Value and units]
I:C Ratio	[Time block]	[Value]
ISF/Correction Factor	[Time block]	[Value and units]
Target Glucose	[Time block]	[Value and units]
Active Insulin Time	[—]	[Value]
Max Bolus	[—]	[Value and units]

Delivery Summary: [TDD]; [Basal/Bolus distribution %]; [Auto vs manual delivery % if AID]

Subjective

[HPI summarizing device-related concerns, interval since last device visit, and relevant context changes] (2–4 sentences. Include illness, schedule/activity/weight changes, new device/insulin only if pertinent.)

• Hypoglycemia events: [Frequency, timing, severity, assistance/glucagon use, triggers]
• Hyperglycemia/ketosis: [Frequency, timing, highest values, ketone presence, sick-day protocol use]
• Device usability: [CGM wear/adherence, bolusing patterns, auto-mode usage, alert burden]
• Infusion site/pod issues: [Site longevity, occlusions, irritation, adhesion, rotation]
• Supply/access: [Availability, insurance/PA issues, backup supplies on hand]
• Patient goals for today: [Stated goals in patient's words]

Objective

• Data Quality: [Download dates]; [Days captured]; [CGM % wear]; [Gaps limiting interpretation]
• CGM Metrics: [Mean glucose]; [TIR %]; [TBR %]; [TAR %]; [%CV]; [GMI] (Include sleep/wake segmentation if available.)
• Pump/AID Metrics: [TDD]; [Auto-mode engagement %]; [Bolus behavior indicators as available]
• Pattern Interpretation: [Overnight patterns]; [Morning/breakfast trends]; [Midday trends]; [Evening/dinner trends]; [Exercise-related patterns] (Anchor observations to the data window. Note suspected sensor artifacts if present.)
• Vitals/Labs: [Results if obtained and pertinent to insulin decisions today] (Omit if not relevant.)

Assessment

(Problem-oriented list in decreasing severity. Keep each problem 1–3 lines, data-anchored.)

• Diabetes control on pump/AID: [Summary referencing CGM metrics, key risks/strengths, loop engagement]
• Hypoglycemia risk: [Timing/patterns, contributors, severity risk]
• Hyperglycemia/ketosis risk: [Timing/patterns, contributors, DKA risk considerations]
• Technology/adherence barriers: [Site failures, alert fatigue, supply access, training needs] (Include only if applicable.)

Plan

Settings Changes

(Complete only if changes were made. Document that settings were updated on-device and verified via read-back, screenshot, or patient demonstration.)

Parameter	Time Block	Before	After	Rationale
[Setting name]	[Time block]	[Before value]	[After value]	[Data-based rationale]

Patient Instructions: [Actionable steps for patient after changes—bolusing timing, carb entry, exercise mode, set changes, alert responses]

(If no changes were made, state why and describe plan for follow-up data review.)

Safety Plan

• Hypoglycemia Mitigation: [Alert adjustments, treatment plan, glucagon availability, driving/work/school considerations] (If not addressed, document "not reviewed today" with reason.)
• Hyperglycemia/Ketone/DKA Prevention: [Steps for persistent highs, when to check ketones, when to change set/pod, when to give injection correction, escalation thresholds] (If not addressed, document "not reviewed today" with reason.)
• Pump Failure Plan: [Immediate steps, back-up insulin instructions, how to obtain urgent supplies] (If not addressed, document "not reviewed today" with reason.)

Education

[Topics taught]; [Who received education]; [Method]; [How comprehension was confirmed] (Include only if education was performed.)

Prescriptions and Supplies

[Pump supplies refilled]; [CGM sensors/transmitters]; [Insulins: pump and back-up]; [Glucagon]; [Prior authorization status] (Include only items addressed today.)

Follow-up

[Follow-up interval]; [Interim remote review if planned]; [Data upload instructions]; [What to monitor and when to reach out]